Community Participation in Chronic Disease Management: Development of a Local Model for Hypertension, Diabetes, and Cancer Care in Hua Pa Subdistrict

Abstract

          Non-communicable diseases (NCDs), including hypertension, diabetes, and cancers (breast, cervical, and colorectal), remain major public health challenges in Thailand. Sustainable management of chronic diseases requires strong community participation, consistent with the Chronic Care Model (CCM), which emphasizes coordinated action among local health stakeholders. This study aimed to develop and evaluate a community participation model for managing hypertension, diabetes, and selected cancers in Hua Pa Subdistrict, Sing Buri Province. A mixed-methods design was employed within a participatory action research framework, following the PAOR cycle: Planning, Action, Observation, and Reflection. Quantitative data were collected from 700 residents using health behavior questionnaires and chronic disease screening results, while qualitative data were obtained through focus group discussions with 15 village health volunteers (VHVs) from four villages. Quantitative data were analyzed using descriptive statistics and chi-square tests, and qualitative data were analyzed using content analysis.
               Findings demonstrated that the model comprised three core components: (1) coordinated mechanisms among local health partners through joint planning and review platforms; (2) empowerment of community members through enhanced health knowledge, self-care skills, and health promotion activities based on the “3E–2S” principles; and (3) a digital health monitoring system using the Smart VHV platform to support data management and follow-up of at-risk individuals. After implementation, the screening rate for hypertension increased from 70.3% to 77.2%, and for diabetes from 70.1% to 80.9% (p < 0.05). Individuals with favorable health behaviors were significantly more likely to have normal screening results. Qualitative findings indicated that continuous engagement among community stakeholders fostered a shared sense of responsibility and strengthened proactive primary care services.
          In conclusion, the developed community participation model effectively improved screening coverage, reduced health-risk behaviors, and reinforced the primary health care system at the subdistrict level. Ongoing capacity-building for village health volunteers, expanded use of digital tools, and integration of the model into local government health policies are recommended to ensure sustainability and support scale-up to other communities.